Abstract DP016: Comparative Efficacy of Interventions for Supratentorial Stroke: A Bayesian NMA with Meta-Regression

Methods: We synthesized evidence from 43 randomized trials (87 arms; 3,399 patients) of supratentorial stroke—predominantly intracerebral haemorrhage—comparing surgical (craniotomy, minimally invasive surgery [MIS] including endoscopic evacuation, decompressive craniectomy) and pharmacologic strategies against standard care. Primary outcomes were 6-month all-cause mortality and functional status (mRS). A Bayesian random-effects network meta-analysis (HalfNormal(0,0.5) prior on τ) used standard care as the reference; network meta-regression (NMR) examined prespecified covariates (age, ICH volume, GCS, NIHSS, timing, etc.). Consistency was assessed by node-splitting and a design-by-treatment test; small-study effects by comparison-adjusted funnel and Egger regression. Results: The network was well connected (27 interventions across 36 trials). Surgery outperformed medical management. Endoscopic MIS reduced mortality (RR≈0.66) and increased functional independence (RR≈1.31 for good outcome) versus conservative care; craniotomy also lowered mortality (RR≈0.75). Pharmacologic options (e.g., tranexamic acid, atorvastatin, cerebrolysin) showed no significant benefit for mortality or function compared with standard care. Ranking favoured endoscopic MIS (SUCRA ≈85%) and stereotactic MIS (≈80%); standard care ranked lowest. Between-study heterogeneity was low (τ≈0.10; I^2≈14%). There was no global inconsistency (design-by-treatment P=0.32). Funnel plots and Egger tests suggested no important small-study bias (P>0.25). NMR identified earlier treatment (<24 h) as a significant effect modifier, with greater functional gains when surgery was performed sooner. Other baseline factors (ICH volume, level of consciousness, NIHSS) did not meaningfully modify relative treatment effects; regression coefficients centered near zero with wide credible intervals. Conclusions: For acute supratentorial ICH, surgical approaches—especially minimally invasive endoscopic evacuation—yield superior 6-month survival and functional outcomes compared with medical therapy alone. Conventional craniotomy confers a moderate survival advantage. Pharmacologic adjuncts did not improve hard outcomes in this network. These findings support prioritizing early MIS (endoscopic or stereotactic evacuation) in eligible patients, with further research needed to refine selection by hematoma size and timing.